Friday, January 22, 2010

C-Section Controversy

Every Year all leading Newspapers raise concern about rising C- Section rate in India. For a good measure they compare rates in other parts of World. There is no doubt that C-sections are done more often now than some 50 yrs ago. usually high rate is considered as bad thing because it is believed-wrongly in my opinion- that more c-sections are done by Doctors because they get more money. if that was the case than China should not have 43% rate as Chinese doctors are employee of the state.

Today WHO report has indicated that C-section rate in India is 18% but in Cities the rate is much higher-about 40%.Lancet in an article has pointed out that unnecessary C.S. has resulted in more admission in I.C.U and more Maternal deaths.Now it stands to reason that if more problems and even death can occur than no obstetrician would like to do unnecessary C.S. and get into trouble. i am working for last 40 yrs as Ob/Gyn. We have discussed this often among collegues and in saminars(In Newspapers as well) and frankly most of us would not like to do C.S. cause we get more money. Main driving force behind this increase is not Money but Reluctance to take Risk by both Parents and Doctors and Premium on the unborn child. For an Obstetrician in city/Metro, losing a Baby is Catastrophe. The whole aim is to see that Mother goes home with healthy baby. There is no reward for Normal Vaginal Delivery if Baby requires extensive NICU care or has Birth Injury. In 60s and 70s we used to deliver even Primi( 1st delivery) with Breech Vaginally but today we are scared to deliver Breech baby Vaginally because if Head is not delivered in less than 5 mts. baby would be dead or severely damaged. This is just not acceptable to parents and Doctors, and is bad for practice.

Assuming 18% overall rate for C.S. in India( WHO) and 40% in urban area its clear that C.S.in rural area is very low. But it's Rural region which has highest Maternal and Neonatal Mortality. If Vaginal delivery is safe and is better choice than result also should be better. Maternal Mortality in urban areas is now primarily due to Hemorrhage from Atonic Uterus( Uterus which doesn't contract) Bleeding disorder caused by Pregnancy hypertension,or some severe Medical Condition. This can occur irrespective of mode of delivery.

It's in the case of well being of the Baby that C.S.is overused. As has happened all over the world, Electronic Monitoring of Foetus( Baby) in 8-9 months in mothers who are elderly (Average age is now 30+),Hypertensive, pre Diabetic,or have Small for Dates babies( IUGR-babies weighing less than 1.5Kg at 9 monts) is routine. Most of the mothers undergo repeated Sonogram where weight of the baby(IUGR), Amount of Liquor around baby( AFI),placental Calcification,Doppler Studies to see Blood Flow to Baby is measured. NST is done. if any of these finding is abnormal than there is possibility of risk to the Unborn Child. So far we have not been able to exactly predict the risk.Even with similar findings Sometimes at C.S., baby is delivered which is absolutely normal and at other baby requires NICU care. Now who should take decision in such cases? Both Doctors and Parents tend to err on safety and go for C.S. rather than attempt Vaginal Delivery. I have had cases when I have decided to wait for a day and have lost baby. In such cases its difficult to explain loss and one is libel to face legal Action and sometimes Violence from relatives. In case of Pregnancy achieved by I.V.F.( Test Tube Baby) Elective C.S. is done.

So the debate will go on. As long as we can not exactly asses risk to unborn Child,C.S. will be done at slightest hint of any risk to the baby. In face of Abnormal Sonogram or NST Report what would you decide? If you cant take risk of (may be) loosing the baby than dont expect Doctor to do so.

If you believe that C.S. is done because doctor gets more money than pay your Doctor same amount whether Delivery is by C.S. or Normal. Put your money where your....